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Documents and forms

The Atos Medical Insurance and Reimbursement Team is committed to helping you navigate through the process to make it as smooth and easy as possible, getting the most from your benefits.  We will file claims for durable medical equipment (DME) orders.  We are also working to get in-network with more and more insurance companies which can mean easier access to products and better reimbursement options for you!  Click here for the latest list and check back often!

For an insurance claim to be filed, we need the following to be completed and returned to our office:

  • Patient Services Form (completed and signed by you)
    • Please note you must identify an Authorized Representative/Caregiver Designation if you want anyone to be able to communicate with Atos on your behalf
    • You must check the box under Consent Statement if you want to receive any communication from Atos via email or telephone
  • Prescription Form (completed and signed by your physician/prescriber) Ask your doctor to send Clinical Notes from your last clinical visit within the last year with each new prescription
  • Copies of ALL health insurance cards (front and back), including Primary and Secondary Insurance

The type of DME equipment ordered, laryngectomy supplies or jaw motion rehabilitation supplies, will determine which forms are to be completed.

Some of these forms are available in Spanish and can be found here.

MC2345 Patient Services Book
  • Important Patient and Privacy Information
View Document
MC2346 Patient Services Form
  • By signing, I acknowledge that I have received a copy of the above Patient Services Book which contains Patient Bill of Rights and Responsibilities, Patient Service Agreement, Notice of Privacy Practices (HIPAA), Ordering Laryngectomy Supplies and Understanding Your Insurance Benefits.
View Document
MC1753 Consent Form, English
  • To help us provide great customer service and deliver our products directly to you, please complete and return
View Document
MC1724 Prescription Form - Laryngectomy
  • Must be completed by treating physician
View Document
MC2311 Prescription Guidance
  • Guidance for Completing a Valid Prescription
View Document
MC2378 Prescription Form - Jaw Motion Rehabilitation
  • Must be completed by treating physician
View Document
AM0006 Medicare Compliance Form
  • An affirmative statement by the Medicare beneficiary instructing Atos Medical not to file a claim to Medicare on the beneficiary's behalf when purchasing durable medical equipment, L8509, indwelling voice prosthesis. The beneficiary does not desire a Medicare claim to be filed and therefore understands there is no further appeal for payment.
View Document
Medicare Provider Enrollment, Chain of Ownership System (PECOS)
  • For any durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items to qualify for coverage by Medicare it must be ordered by a physician or a practitioner who is eligible to order such item.
View Document
AM0005 CMS Medicare DMEPOS Supplier Standards
  • CMS Medicare DMEPOS Supplier Standards
View Document